**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure residents were free from abuse for three (3) of five (5) residents (Resident ID # 2, #3 and #7). The facility failed to ensure interventions were in place to address verbal altercations which occurred prior to a physical altercation between Resident #1 and Resident #2, and for Resident #3 and #7 the facility failed to ensure the residents were free from physical and psychosocial abuse. The findings included: 1. Resident #1 had diagnoses which included schizoaffective disorder, bipolar disorder, and schizophrenia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1, had a Brief Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, was independent with Activities of Daily Living (ADL) including ambulation, did not present with hallucinations or delusions, and did not exhibit any physical, verbal or behavioral symptoms directed toward others. Review of Resident #1's care plan dated 2/11/24 identified Resident #1 had a potential for alteration in mood due to diagnoses of anxiety, bipolar, and schizoaffective disorders and received psychotropic medications with interventions that directed to provide support, medication administration as ordered, and to be alert to a decline in mood/behavior. Resident #2 had diagnoses which included cerebral infarction, hemiplegia affecting left, nondominant side, and adjustment disorder. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and required substantial assistance with ADL's and was non-ambulatory. Review of Resident #2's Care Plan dated 12/19/23 identified a risk for alterations in mood/behavior related to depressive episodes and anxiety disorder with interventions that directed to encourage resident to verbalize feelings and fears, to spend time talking to the resident, and to allow expression of feelings. Review of Social Worker (SW) #1's note dated 12/19/23 identified Resident #2 had concerns with his roommate (Resident #1), wanted to move to another room, and that SW #1 would assist. No further documentation about the room change was identified and the facility census on 2/15/24 identified Resident #2 remained in the room with Resident #1. Review of a nurse's note dated 2/15/24 at 8:58 AM identified that Resident #2 alleged that Resident #1 had stuck him/her in the face, the resident had a swollen bloody lip. Review of the Facility Licensing and Investigations Section Reportable Event form dated 2/15/24 identified that Resident #1 punched Resident #2 in the face because Resident #1 thought Resident #2 was the devil. The residents were immediately separated, and Resident #1 was transported to the hospital. Review of the police report dated 2/15/24 at 8:16 AM identified a physical altercation occurred between two roommates, Resident #1 and Resident #2. Interview with Resident #2 identified that Resident #1 came out of the bathroom, charged at Resident #2, and began punching him/her in the face. The police report further identified that Resident #1 then fell on top of Resident #2, causing a head-to-head collision, and a minor cut was observed on Resident #2's bottom lip. The police report noted in an interview with Resident #1 identified that he hit Resident #2 because he/she thought Resident #2 was the devil. Resident #1 was transferred to the hospital for evaluation. Review of a hospital Discharge summary dated [DATE] identified that Resident #1 denied suicidal or homicidal ideation and did not meet the criteria for inpatient psychiatric hospitalization and was sent back to the skilled nursing facility. A nurse's note dated 2/15/24 at 10:53 PM identified that Resident #1 had returned from the hospital and moved to a different room, (with no roommate) and no behaviors were noted. Interview with Resident #2 on 10/2/24 at 8:52 AM identified he/she had requested a room change in December 2023 as he/she felt his roommate (Resident #1) was mentally unstable. Resident #2 identified feeling uncomfortable with the living situation and was concerned for his/her safety as he/she was unsure when a situation would become violent. Resident #2 further indicated he/she informed the Social Worker that he/she did not want to share a room with Resident #1 any longer and was told there were no rooms available. Resident #2 indicated he/she had to deal with the situation and tried to ignore Resident #1's verbal outbursts as the room change did not occur. Interview with Licensed Practical Nurse (LPN) #1 on 9/30/24 at 11:04 AM identified he/she did not witness the incident between Resident #1 and Resident #2 on 2/15/24, however had gone to the residents' room and saw Resident #2 sitting on the edge of his/her bed, bleeding from the mouth, crying, and visibly upset. LPN #1 further identified Resident #2 had reported he/she was attacked and did not retaliate due to weakness from his/her stroke and fear of getting into trouble. LPN #1 indicated Resident #1 was placed on one-to -one supervision until sent to the emergency room for further evaluation. Interview with Social Worker (SW) #1 on 10/1/24 at 3:03 PM identified Resident #1 would frequently make negative and racist remarks to Resident #2 prior to the 2/15/24 incident. These remarks consisted of Resident #1 calling Resident #2 evil, the devil, racist remarks, and complaining about him/her leaving the bathroom unclean, however, there were no physical altercations were noted prior to 2/15/24. SW #1 indicated he/she had informed Administrator #2 (previous administrator) of their first argument, she could not recall the exact date, she identified it was sometime in December 2023. SW #1 further identified he/she did not move Resident #2 at that time of his/her request on 12/19/23 because he/she thought there were no empty beds available. SW #1 identified that the arguments between Resident #1 and Resident #2 had continued and after the second argument which SW #1 estimated had occurred sometime in January 2024, he/she again informed Administrator #2, and was instructed to move one of the residents to a new room, however both residents refused to move. SW#1 further identified that she did not document the ongoing arguments in the clinical record and was unsure why. Interview with Administrator #2 (Administrator in place at the time of the incident) on 10/1/24 at 4:02 PM identified he/she remembered the altercation between Resident #1 and Resident #2 on 2/15/24, however could not recall being informed that any verbal exchanges/concerns between the two residents occurred prior to the 2/15/24 incident. Administrator #2 identified anytime a physical or verbal incident had taken place, the resident's room would immediately be changed. Interview with the Administrator #1 (current administrator) 10/3/24 AT 9:30 AM identified rooms were available on the long-term care unit in December 2023. Interview with the Director of Nurses (DON) on 10/1/24 at 9:12 AM identified that Resident #1 was cleared psychiatrically on 2/15/24 and sent back to the facility and placed into a private room. The DON stated that she was not aware of any of the verbal exchanges that occurred between Resident #1 and Resident #2 prior to the 2/15/24 incident and was not informed by SW #1 that this was occurring. The DON further identified he/she would have immediately separated the residents had she known the verbal exchanges were taking place as it created an unsafe situation and would have also involved different disciplines to support/inquire about the issue and hopefully resolve it. 2. Resident #7 had diagnoses that included schizophrenia, generalized anxiety disorder, and congestive heart failure. Review of the quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 had a Brief Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition and was independent with ADLs and ambulation. Review of Resident #7's Care Plan dated 4/3/24 identified an alteration in mood state with interventions that directed to monitor for irritability, anxiety, depression, and any mood changes. A nurse's note dated 6/9/24 at 3:43 PM Resident #1 was noted to hit staff and a resident, 911 and a doctor strong (an emergency code for immediate assistance) was called. Resident #1 broke free from staff and hit another resident in the head. Review of the Facility Licensing and Investigations Section Reportable Event form dated 6/9/24 at 3:30 PM identified Resident #7 was standing at the nurse's station when he/she was punched on the side of the face by Resident #1. Resident #7 was assessed and no injuries were identified and Resident #1 was transferred to the hospital. Review of the police report dated 6/9/24 at 4:01 PM identified a physical altercation between a resident and staff member, where Resident #1 had a mental episode and jumped on LPN #2's back and then punched another resident in the face. The report further indicated Resident #1 was calm, in the presence of staff, sitting in a wheelchair upon police arrival to the facility. The report identified Resident #1 was transported to the hospital following the incident. Review of a care plan dated 7/1/24 identified that the resident had been hospitalized after hitting a resident and a staff member and had returned to the facility on 7/1/24 and was placed on one-to-one supervision until 7/11/24, when every fifteen-minute checks were initiated. Although the hospital discharge summary for the hospital stay from 6/9/24-7/1/24 was requested it was not provided. Interview with Resident #7 on 10/3/24 at 1:50 PM identified he/she was hit in the head, back and arms by Resident #1 on 6/9/24, that Resident #1 had punched him/her hard, called him/her a demon, and threatened to kill me. Resident #7 further identified that he/she still has flashbacks of the incident and was frightened after the incident. Interview with LPN #2 on 10/2/24 at 3:40 PM identified he/she had walked into the unit at 3:00 PM on 6/9/24, and walked into the nurse's station to receive report, and that Resident #1 had followed him and started hitting him with his/her fist in the back and then on the chest. LPN #2 further identified the floor staff assisted in separating the resident from LPN #2 and had placed Resident #1 in a wheelchair in front of the nurse's station under the supervision of staff. LPN #2 indicated he/she stepped away from the incident and was at the elevator when he/she heard commotion at the nurse's desk and heard Resident #1 had hit Resident #7. Interview with Nurse Aide (NA) #1 on 10/2/24 at 10:12 AM identified witnessing Resident #1 hitting LPN #2 on 6/9/24 and that, five (5) staff members separated Resident #1 from LPN #2, Resident #1 was placed in a wheelchair near the nurse's station under staff supervision. NA #1 identified staff had attempted to calm Resident #1 down, but Resident #1 had gotten up from the wheelchair, and ran into a resident ' s room, grabbed an overbed table, and brought it into the hallway as Resident #7 was approaching the nurse's station. Resident #1 then broke away from staff and ran over to Resident #7 started hitting Resident #7 in the head and calling him/her a demon. NA #1 further indicated Resident #7 was crying following the incident and was taken to his/her room where he/she remained until Resident #1 was transferred out of the facility. Interview with the Regional Clinical Consultant on 10/3/24 at 3:00 PM identified that Resident #1 had an extended hospital stay and upon return was placed on one-to-one supervision until 7/11/24, the resident had not exhibited behaviors so the interdisciplinary team decided every 15 minute checks was appropriate, the resident then was on every 30 minute checks and then every hour checks until they were discontinued due to a hospital stay for another physical altercation with a resident on 9/13/24. 3. Resident #3 had diagnoses which included disorganized schizophrenia, anxiety disorder, and encephalopathy. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12) indicative of moderately impaired cognition, did not exhibit physical or verbal behaviors towards others, and was independent with ADLs. Review of the Care Plan dated 7/25/24 identified Resident #3 had memory loss, impaired cognition, and was at risk for communication impairment with interventions that directed to face resident when speaking, and if resident was restless/agitated, to reapproach later in a calm, soothing manner. Review of the Facility Licensing and Investigations Section Reportable Event form dated 9/13/24 identified that Resident #1 attacked Resident #3 and was punching him/her in the face. Both residents were assessed, and no injuries were noted. Review of the police report dated 9/13/24 at 9:51 AM identified an altercation between Resident #1 and Resident #3 where Resident #1 had punched Resident #3 in the head and a scuffle had ensued. The report further indicated Resident #3 had identified Resident #1 had struck him/her in the head for no reason while he/she was walking by and threatened that he/she was going to get a gun and come back and shoot Resident #1. When the police officer asked Resident #1 what had occurred, Resident #1 responded, I saw the devil in that person. Both residents were sent to the emergency room for further evaluation. Interview with Occupational Therapist (OT) #1 on 9/30/24 at 2:46 PM identified that on 9/13/24, he was following Resident #1 with a wheelchair as he/she was walking in the hallway and had passed by Resident #3 who was ambulating in the hallway in the opposite direction when Resident #1 punched Resident #3. OT #1 further indicated Resident #3 retaliated and punched back at Resident #1. OT #1 identified the staff were able to successfully separate the two residents and that Resident #1 had stated Resident #3 was the devil. Both residents were sent to the emergency room for further evaluation. Interview with the Administrator on 10/3/24 at 5:10 PM identified that she was the administrator when the incident on 9/13/24 occurred. Resident #1 was sent to the hospital and subsequently transferred to another facility better suited for the resident's needs. The administrator further identified that the facility has zero tolerance any form of abuse. Review of the abuse policy identified that the residents in the facility will be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy and interviews, for one of two sampled residents (Resident #375) reviewed for pain management, the facility failed to administer pain medication when the resident made a request to be medicated. The findings include: Resident #375 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), cellulitis (infection of the skin) of right lower limb, and chronic pain syndrome. The admission MDS assessment dated [DATE] identified Resident #375 had moderately impaired cognition, required minimal assistance with personal hygiene and required the assistance of two staff members with dressing, positioning, and transfers. The assessment further noted that the resident had an almost constant presence of pain. The care plan dated 11/12/23 identified Resident #375 was at risk for pain with interventions that included: administer pain medication as indicated and observe for vocal complaints of pain and non-verbal sounds such as crying, moaning, or groaning. A physician's order dated 11/22/23 directed to administer Oxycodone (opioid) 20 milligram (mg) by mouth every 4 hours as needed for moderate to severe pain. Interview on 12/05/23 at 3:00 PM with Resident #375 identified that the for two days of the previous week, the facility did not have his/her pain medication available. Resident #375 further identified that he/she felt like he/she was losing his/her mind due to the level of pain. A nurse's note dated 11/29/23 at 8:39 AM identified Resident #375 complained of pain at 6:45 AM, was screaming, and was told that the medication had not arrived from the pharmacy and was not in the facility's emergency medication supply. In addition, the note identified that the resident declined to be sent to the emergency room and conveyed that they would not help her and would just say that the emergency room is not for pain management. A review of the audit report for the Omnicell machine (an automatic medication dispensing system) which is used to store the facility's emergency supply of medications and requires the nurses to log in with personal log in information. The audit identified that the DNS and the ADNS logged into the system on 11/29/23 at 12:15 PM and noted that the facility had 20 tablets of Oxycodone 10mg available at that time. The audit report identified that the DNS and the ADNS were the only staff that logged into the system on 11/29/23. A progress note written by APRN #1 dated 11/29/23 at 2:40 PM identified she was asked to see Resident #375 for agitation, a pain level of 10 out of 10 (based on a pain scale of 1-10 with 10 being the highest level) for back and lower extremities, increased agitation and crying out for pain medication. The note further identified that the order previous order for Oxycodone was renewed, and a script faxed to the pharmacy. A nurse's note dated 11/29/23 at 10:08 PM identified that the Oxycodone was delivered from the pharmacy at 9:30 PM and the resident was administered the pain medication (approximately 15 hours from the time the resident requested the medications and was noted to have a pain level of 10). Review of the medication administration record (MAR) identified that the resident was medicated as requested according to the physician's orders on 11/28/23, thus did not go two days without pain medication. Interview on 12/11/23 at 3:12 PM with the Nursing Supervisor (RN #7) who was the 11:00 PM to 7:00 AM shift supervisor working on 11/29/23 identified that the charge nurse reported Resident #375 requested pain medication and that the resident did not have any available. She further noted that she checked the Omnicell for Oxycodone but there was none available. She did not explain how she accessed the Omnicell without logging into the system (which is necessary to ascertain the availability of any of the emergency medications). Interview with the DNS on 12/11/23 at 2:44 PM identified she was notified on 11/29/23 that Resident #375 and the emergency box was out of Oxycodone. The DNS indicated that she checked the emergency box and Oxycodone was available. The DNS further indicated that if a resident is out of a medication the emergency supply should be checked. The DNS identified that there should not have been a delay with medicating Resident #375 because the Oxycodone was available. The DNS did not explain why the medication was not administered to the resident when she accessed the Omnicell and determined that it contained 20 tabs of Oxycodone 10mg. Review of the facility's policy on Medication Shortage/Unavailable Medication identified that if the next available delivery of the medication will result in a missed or delayed dose of the resident's medication, the medication should be taken from the emergency medication supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation review, facility policy review and interviews for one of two residents (Resident #90) reviewed for accidents, the facility failed to ensure staff supported the resident's head, neck, and back in accordance with facility policy during a mechanical lift (Hoyer) transfer to prevent a fall with injury. The findings include: Resident #90's diagnoses included cerebrovascular accident with hemiplegia and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #90 had severe cognitive impairment, no behavioral symptoms, was non-ambulatory, required total assistance of two staff for bed mobility and transfers, and had limited bilateral upper extremities range of motion. The Resident Care Plan (RCP) dated 7/28/2021 identified Resident #90 was at risk for falls due to weakness, abnormal posture and utilized a total mechanical lift for transfers with assist of two. Interventions directed to provide assistance with bed mobility, and transfers. Physician's monthly orders dated 8/10/2021 directed to transfer Resident #90 utilizing a Hoyer lift with assist of two and identified that Resident #90 utilized a tilt in space customized wheelchair with a pelvic positioning belt. Review of facility reportable event report dated 8/27/2021 at 1:10 PM identified during a Hoyer lift (mechanical lift) transfer with two nurse aides present, Resident #90 slid off the Hoyer lift pad, hit her/his head on the frame of the Hoyer lift and landed on his/her buttocks on the floor. The Hoyer pad remained attached to the Hoyer lift when the fall occurred. The report further identified that the resident was immediately seen by the APRN and sent to the hospital emergency department for evaluation. Review of NA #1's written statement identified that she supported Resident #90's legs during the Hoyer lift transfer when Resident #90 moved to the right side and fell to the floor. Review of NA #3's written statement identified that she was operating the Hoyer lift and supporting Resident #90's head during the Hoyer lift transfer, and Resident #90 moved to the right side and fell to the floor. Review of the hospital documentation identified that Resident #90 was admitted to the hospital on [DATE] and had a Computerized Tomography (CT) Scan of the head and cervical spine. CT scan results identified Resident #90 had a comminuted acute fracture of the anterior arch of cervical vertebrae #1 (C1), extending into the bilateral lateral masses, and an acute fracture of the left superior articular facet of cervical vertebrae #2 (C2). Nurse's note dated 8/28/2021 at 12:24 PM identified Resident #90 returned to the facility at 10:30 AM via stretcher, was alert and responsive, and denied pain. The note further indicated that Resident #90 had a C1 and C2 fracture and was wearing a Miami J neck collar. Review of Physicians order dated 8/28/2021 directed Resident #90 was to wear a Miami J collar at all times. The order further directed the charge nurse to be present with two (2) NAs for all Hoyer lift transfers. Interview and facility documentation review with NA #3 on 9/7/2021 at 2:48 PM identified that during Resident #90's Hoyer lift transfer from the bed to the wheelchair on 8/27/2021, she was standing at the Hoyer lift controls while NA #1 supported Resident #90's legs for balance. When Resident #90 was lifted off the bed, she indicated that Resident #90's upper body was not supported. She further indicated that when Resident #90 was in the air in the Hoyer sling over the floor, she moved the Hoyer lift to turn the Hoyer lift in the room and she reached away for a moment (leaving Resident #90's upper body without guidance or support from her) to bring the wheelchair into position for completing the transfer. While Resident #90's upper body had no support provided by NA #3, Resident #90 leaned toward the right and fell out of the Hoyer sling to the floor. Interview and observation of a re-enactment demonstration of the transfer with NA #1 and NA #3 on 9/9/2021 at 1:25 PM identified that Resident #90's wheelchair was not placed near the bed prior to raising Resident #90 off the bed with the Hoyer lift. The demonstration identified Resident #90 was lifted off the bed and the Hoyer lift was parallel to the bed when NA #3 stepped away from Resident #90 (Resdient #90 was in the air over the floor), and Resident #90's upper body was without any staff support in the Hoyer lift sling. NA #3 indicated that when she moved away from Resident #90 to bring the wheelchair close to Resident #90, Resident #90 moved to the right side and fell to the floor. Interview with NA #1 on 9/21/21 at 2:38 PM identified that she supported Resident #90's legs while NA #3 operated the Hoyer lift, and NA #3 did not provide upper body support to Resident #90 during the transfer. She indicated that after Resident #90 was lifted off the bed and was in the air (in the Hoyer sling) over the floor, NA #3 was not holding onto Resident #90's upper body. She identified that when Resident #90 was in the air, NA #3 attempted to bring the wheelchair into position, and Resident #90's upper body had no support provided by NA #3. She further indicated that Resident #90 moved when she and NA #3 tried to reposition him/her in the sling while in the air and when his/her upper body was not provided support by NA #3, Resident #90 tilted to the right and fell out of Hoyer lift onto the floor. Interview with the Director of Nursing (DON) on 9/21/2021 at 3:20 PM identified that NA #3 failed to support Resident #90's upper body during the Hoyer lift transfer on 8/27/2021, in accordance with facility policy, and Resident #90 fell to the floor. She indicated that Resident #90 required more support during transfers than two (2) staff were able to provide. The DON identified that since the fall on 8/27/2021 additional supervision was provided for Resident #90 for all transfers to ensure safety. The care plan was updated to direct all transfers were performed by three (3) staff, and the third person must be the charge nurse. She further indicated that staff should have provided support to Resident #90's upper body during the transfer. Review of the facility Safe Lifting and Movement Policy dated 9/2017, directed in part, that only staff with documented trained on the safe use of the machines will be allowed to lift or move residents. Review of the facility Lifting Machine, Using a Mechanical Policy, dated July 2017, directed in part to assess the resident's current condition, including can the resident understand and follow instructions, does the resident express fear, appear anxious, is agitated, resistant or combative. The Policy further directed to attach the sling straps to the sling bar, make sure the sling is securely attached to the clips and properly balanced. Further the Policy directed to make sure the resident's head, neck and back are supported. and to support the resident as he/she is moved.